FINAL REPORT FATAL INJURY AT SEA ON BOARD TANKER BOW … · 8/8/2018 · 1.1.3 At about 0830H, an...

FINAL REPORT

FATAL INJURY AT SEA

ON BOARD TANKER

BOW SUN

ON 8 AUGUST 2018

MIB/MAI/CAS.048

Transport Safety Investigation Bureau Ministry of Transport

Singapore

21 May 2020

© 2020 Government of Singapore ii

The Transport Safety Investigation Bureau of Singapore

The Transport Safety Investigation Bureau (TSIB) is the air, marine and rail accidents and incidents investigation authority in Singapore. Its mission is to promote transport safety through the conduct of independent investigations into air, marine and rail accidents and incidents.

The TSIB conducts marine safety investigations in accordance with the Casualty Investigation Code under SOLAS Regulation XI-1/6 adopted by the International Maritime Organisation (IMO) Resolution MSC 255 (84).

The sole objective of TSIB’s marine safety investigations is the prevention of marine accidents and incidents. The safety investigations do not seek to apportion blame or liability. Accordingly, TSIB reports should not be used to assign blame or determine liability.

© 2020 Government of Singapore iii

CONTENTS PAGE

SYNOPSIS 1

1 Factual information 3

1.1 Sequence of events 3

1.2 The ship 5

1.3 The crew 7

1.4 Additional information 8

1.5 The Safety Management System 12

1.6 Relevant safe working practice 14

1.7 Cause of death 14

1.8 Environmental condition 14

2 Analysis 16

2.1 The occurrence 16

2.2 Type of knot used to secure the flange 17

2.3 Risk assessment for shipboard operations 18

2.4 Incidental findings 18

3 Conclusions 21

4 Safety actions 22

5 Safety recommendations 23

© 2020 Government of Singapore 1

SYNOPSIS

On 8 August 2018, at about 0908H, the Singapore registered oil/chemical tanker,

Bow Sun, was transiting the Gulf of Aden enroute to Suez Canal.

The Pumpman was tasked to troubleshoot the cause of loss of suction of the

submersible ballast pump inside the ballast tank with the assistance of another deck crew.

The deck crew was standing by at the entrance while the Pumpman entered the tank

alone. After a metal flange suspected to be the cause of the suction problem was removed

from the pump casing, it was tied by the Pumpman with a rope and instruction was given

to the deck crew to heave it out of the tank. In the process of heaving, the flange, weighing

about 6kg, came loose from the rope and dropped into the tank from a height of more

than 5m and hit the Pumpman’s head. The Pumpman suffered severe head injury and

was evacuated for medical care but succumbed to the injuries at the hospital few days

later.

The Transport Safety Investigation Bureau classified the occurrence as Very

Serious Marine Casualty and launched a marine safety investigation.

The investigation revealed that the flange had likely not been tied with an

appropriate knot and which became loose when heaving out of the tank. The Pumpman

was likely attempting to climb up when the flange came loose from the rope. The impact

force of the flange had exceeded the certification requirement of the safety helmet.

The investigation also revealed that there was no risk assessment being carried

out for the troubleshooting of the ballast pump.


DETAILS OF THE SHIP

Name Bow Sun

IMO number 9197284

Flag Singapore

Classification society Det Norske Veritas and Germanischer

Lloyd (DNV-GL)1

Ship type Oil/chemical tanker

Hull Steel

Delivery 1 August 2003

Owners Odfjell Asia II Pte Ltd

Operators / ISM2 Managers

Odfjell Tankers AS / Odfjell Management AS

Gross tonnage 29974

Length overall 182.88m

Moulded breadth 32.20m

Moulded depth 17.95m

Summer draft 12.42m

Draft (Forward / Aft) 11.85m / 11.95m

Bow Sun (Source: the ISM Manager)

1 DNV-GL was the Recognised Organisation (RO) for the flag Administration, for carrying out ISM audit and issuance of ISM related certificates, in addition, DNV-GL was also for survey and issuance of other statutory certificates.

2 International management code for the safe operation of ships and for pollution prevention.


1 FACTUAL INFORMATION

All times used in this report are Ship’s Mean Time (SMT), which was two hours

ahead of the Coordinated Universal Time (UTC), i.e. UTC + 2H, unless

otherwise stated.

1.1 Sequence of events

1.1.1 On 8 August 2018, the Singapore registered oil/chemical tanker, Bow Sun (BS),

was enroute to Suez Canal, transiting the Gulf of Aden.

1.1.2 At about 0730H, the Chief Officer3 called the Bosun4 and the Pumpman5 for a

daily work plan meeting at the ship’s office. The Bosun was to assist with the

remounting of the overhauled air horn on the foremast, while the Pumpman

was to troubleshoot the problems with airtightness of a flange (anode cover) of

the ballast pump6 casing inside no.7 ballast tank, at the port side (7WBT-P).

1.1.3 At about 0830H, an Able Seafarer Deck7(ASD) came on deck to assist the

Pumpman as assigned by the Chief Officer. The ASD started ventilating the

7WBT-P to prepare for entry (opening of the manhole) while the Pumpman was

preparing the tools.

1.1.4 At about 0855H8, the Pumpman with a portable radio for communication

entered 7WBT-P to remove the said flange at the bottom of the tank while the

ASD stood by at the manhole entrance for assistance. The ASD and the

navigating officer on the bridge (the Third Officer9) were also on the same radio

channel. The tools (for use by the Pumpman), put inside a bucket, were

lowered by the ASD using a rope (see paragraph 1.4.3) tied to the bucket.

1.1.5 After about 10 minutes of entering10, according to the ASD, the Pumpman

3 A day worker who had no watchkeeping duties at sea. 4 A day worker who was keeping the assigned security watch (0800H-1200H) at that time. 5 A day worker who was also required to keep security watches (0000H-0400H and 1200H-1600H) if instructed by

the Master. 6 A type of equipment installed on board for transferring or discharging ballast water to adjust ship’s stability. The pump had been known to have lost suction during operations.

7 He kept the 0400H-0800H and 1600H-2000H sea watches. 8 Timing was based on the ship’s log recorded by the bridge duty officer. 9 Kept the 0800H-1200H and 2000H-2400H sea watches. 10 Enclosed space entry log book kept on the bridge contained an entry into 7WBT-P at 0855H.


shouted (did not use the radio)11 to the ASD to heave up the rope, which had

been removed from the bucket of tools and tied to the flange12. The ASD

started13 retrieving the rope.

1.1.6 At about 0908H, the ASD recalled that the rope had been retrieved for about

6-8m, when the tension on the rope was loosened and realised that the flange

had come off from the rope. At about the same time the ASD heard a scream

from the Pumpman in the tank.

1.1.7 Thinking that the flange might have hit the Pumpman, the ASD communicated

on the portable radio to inform the others that the Pumpman might have been

injured.

1.1.8 The Master of BS, who was in the office preparing to go to the ship’s forecastle

to check on remounting status of the air horn, overheard this call on the radio

and had assumed14 that a crewmember had fallen from the foremast while

remounting the air horn.

1.1.9 The Master went to the bridge to find out from the Third Officer on what had

happened. On being informed of an injury inside the ballast tank, the ship’s

general alarm was raised and all crew were instructed to muster at 7WBT-P to

rescue the Pumpman from the tank.

1.1.10 The Chief Officer, who was in the ship’s office, after hearing the ship’s general

alarm and announcement, called for the Bosun (who was on deck) to proceed

to 7WBT-P. On arriving at the scene, the Chief Officer entered the tank and

informed the Master that the Pumpman was lying unconscious at the bottom

platform and bleeding from the head. The Pumpman’s helmet had an

indentation and blood was seen in the vicinity. Considering the severity of the

injury, the Master requested medical assistance from a Japanese coalition

warship (the Akebono)15 in the vicinity and informed the Company (ISM

Manager).

1.1.11 Meanwhile, at about 0927H, the Pumpman was retrieved from the tank and

11 The ASD recalled that they had been using the same mutual understandable signal for heaving up items (e.g. a

bucket of working tools) in the past few occasions working on the ballast pump. 12 More details in paragraph 1.4.2. 13 The ASD recalled noticing the Pumpman was staying away (from the manhole) before lifting the rope. 14 To the Master’s knowledge there was no entry into any tank planned for the day. 15 Warship “108 (Akebono)”, was on a routine security patrolling in the Gulf of Aden against pirate’s activity.


transferred16 to the ship’s infirmary for medical care.

1.1.12 Subsequently, the Chief Officer sought radio medical advice17 while the Master

was discussing with the Akebono (the warship) on the medical arrangement for

the Pumpman.

1.1.13 After assessing the information provided by the Master, at about 0954H, the

Akebono indicated18 its intention to provide medical care to the Pumpman. The

Chief Officer was informed by the Master to prepare for receiving a medical

team. BS was slowed down to facilitate the arrival of the warship’s helicopter.

1.1.14 At about 1049H, the medical team and equipment from the Akebono were

winched down onto BS from the helicopter.

1.1.15 The medical team provided medical care to the Pumpman who regained

consciousness. After a further assessment by the medical team, the Pumpman

was airlifted to the Akebono at about 1210H, and BS resumed its passage to

its destination about 20 minutes later.

1.1.16 The Master was updated that in the late afternoon, the Pumpman was

transferred to a hospital in Djibouti and on 12 August 2018, was transferred to

a hospital in Dubai for further medical treatment19. About a week later, the

Company informed the Master that the Pumpman had passed away at the

hospital in Dubai.

1.2 The ship

1.2.1 BS was a double hull oil and chemical tanker, built with 40 cargo tanks to carry

multiple types of chemical or oil cargo. Her last dry-docking was carried out in

June 2018.

1.2.2 BS had 20 water ballast tanks, most of which were fitted on both port and

starboard sides of cargo tanks to serve as a protection for the cargo tanks as

well as used to maintain ship’s stability.

16 The Pumpman was unconscious but had a shallow breathing. 17 Norwegian centre for maritime medicine, available 24/7, offers medical assistance to ships in need of help for

diagnosing and treatment of diseases and injuries. 18 According to the statement from the Master of BS. 19 The Company had taken the ship’s Protection and Indemnity Club’s advice into consideration on the hospital

transfer.


1.2.3 At the time of the incident, 7WBT-P, which extended from frames (Fr.) 63 to 79,

was empty, as were the other water ballast tanks. To access the tank, two same

sized manholes20 were provided on the main deck port side.

1.2.4 Inside 7WBT-P, a vertical ladder, located at the side of the manhole, which

extended through three platforms provided direct access to the bottom

platform. The estimated height from the bottom platform (where the Pumpman

was found unconscious) to the main deck was about 16m, to platform-2 was

7.7m, and to the platform-1 was about 3m (see figure 1).

Figure 1 – Overview of the 7WBT-P with drawing and picture

(note: the photo was taken on another day after the occurrence from platform 3)

(Source: the ISM Manager)

1.2.5 There was no lighting fitted inside the tank. A clear line of sight to the bottom

platform along the vertical ladder would likely be possible only when the outside

natural light was bright. Portable lights/torchlights would be needed to perform

work inside the tank.

20 One located at the aft frame of the tank and the forward manhole located near the middle of the tank at Fr. 73.

Each manhole had a size of 800mm in length and 600mm in breadth. The Pumpman had used the forward manhole to access the tank which was closer to the location of the pump which was near to Fr. 76.


1.2.6 The bottom of the tank was divided into smaller compartments. The

compartment (where the Pumpman stood) had an area of about 2.5m (length)

x 3.5m (width). The ballast pump was fitted in the adjacent compartment which

was accessible by an opening.

1.3 The crew

1.3.1 At the time of the accident, in addition to the four security armed guards21, BS

was manned by 30 crew of various nationalities. All the crew held valid STCW22

competency certificates required for their respective positions held on board

and had undergone relevant training. The working language on board was

English.

1.3.2 The qualification and experience of the Master, relevant officers and crew

members are tabulated below:

Designation

On board Nationality Age Qualification

Duration

on board

(month)

Experience on

this type of

ship (Year)

In rank

service

(Year)

Service in

Company

(Year)

Master Philippines 42 COC –

Master 0.423 11.6 1.4 17.8

Chief

Officer Norway 36

COC –

Master 1.7 10.1 6 18.1

Second

Officer Philippines 32

COC –

Chief Officer 5.4 6.4 1.8 11.3

Third

Officer Philippines 25

COC –

OOW (Deck) 6.9 3.9 2.2 7.2

Additional

Third

Officer

Philippines 40 COC –

OOW (Deck) <1 6.1 4.6 6.1

Bosun Philippines 44 Deck Rating

as per

STCW

5.0 11 7 17

ASD Philippines 47 2.0 14.9 13 18

Pumpman Philippines 57 3.5 30.7 15.9 31.6

1.3.3 The Chief Officer had been on BS back and forth as assigned by the Company,

having joined BS again when the ship was at the dry-dock in China in June

2018. The Chief Officer was the head of deck department as well as the Safety

Officer on board.

21 The vessel was transiting the International Recognized Transit Corridor (IRTC), with navy ships patrolling within

the area. The IRTC is a navy-patrolled route through the Gulf of Aden detailed in a publication, the Best Management Practices (BMP5) to deter piracy and enhance maritime security in a high risk area such as the Red Sea, Gulf of Aden, Indian Ocean and Arabian Sea.

22 The International Convention on Standards of Training, Certification and Watch keeping for Seafarers (or STCW), 1978 sets qualification standards for masters, officers and watch personnel on seagoing merchant ships.

23 Joined ship on 27 July 2018 and was his first time on BS.


1.3.4 The ASD, served on BS twice in the past, i.e. in 2012 and 2016, before this trip.

Having sailed with the Pumpman three times in the Company, the ASD recalled

the Pumpman as an experienced worker. Prior to the occurrence, the ASD had

been assisting the Pumpman in the past two weeks for various jobs including

troubleshooting and some overhaul of the same ballast pump.

1.3.5 Having joined the Company as a Mess Man in 1986, and after serving one ship

in that capacity, the Pumpman switched over to be a deck rating serving as an

Ordinary Seaman. After being promoted in 1989 to ASD and to Bosun in 1994,

the Pumpman started working in the current rank eight years later, i.e. since

2002.

1.3.6 The Pumpman’s medical certificate24 and records indicated that all check-ups

including eye sight (with spectacles) and hearing test were within acceptable

limits for service at sea as a deck rating without any restrictions or prescribed

medication.

1.3.1 According to the Company’s structure, the Pumpman’s job scope, amongst

others, was relating to operation of cargo/ballast pump and reporting to the

Chief Officer for such matters. The Pumpman could also take instructions for

other maintenance works from the Chief Engineer and was considered as a

Petty Officer according to the Company’s SMS.

1.4 Additional information

1.4.1 Ballast pump on board

1.4.1.1 BS was installed with one ballast pump (submersible type25) inside the 7WBT-

P and another similar type was inside the 7WBT-S (starboard), each with a

pumping capacity of 800m³ per hour. At the time of occurrence (and on prior

occasions), the pump inside 7WBT-P had been reported to lose suction while

the one in 7WBT-S was in operational condition.

24 Issued on 9 March 2018 and had a 2-year validity. 25 Commonly installed in the water ballast tanks on tankers to reduce excessive use of space for pump rooms.


1.4.1.2 For compliance with ballast water management regulations26, a ballast water

treatment system (BWTS) was installed27 on deck near no.8 cargo tank on the

port side during BS’s dry-docking in June 2018. Prior to the installation, the

Company had carried out a feasibility study to assess whether the installation

of the BWTS required modifications to the existing ballast system. The study

revealed that no modifications were needed and that the BWTS could be

connected to the existing ballast system.

1.4.1.3 According to the Chief Officer’s experience on board since this installation, the

problems related to this ballast pump had undergone troubleshooting28 several

times.

1.4.1.4 According to the ASD, prior to the occurrence, troubleshooting for the ballast

pump had been carried out in the past two weeks, which included an overhaul

of the pump by the duo on two occasions. Details of the kind of overhaul carried

out was not available for the investigation team.

1.4.1.5 A sacrificial anode was fitted on the casing of the pump to minimise corrosion,

which was secured by a flange. The ASD recalled being informed by the

Pumpman that this flange could be the cause of the loss of suction. (see figure

2).

Figure 2 – Drawing of the ballast pump and location of the flange, annotated by TSIB


26 The International Convention for the control and management of ships’ ballast water and sediments, 2004,

entered into force globally on 8 September 2017. 27 As the ballast pump was submersible type, the BWTS had to be installed on deck, which would increase the lifting

height and pressure drop, to maintain a satisfactory output, the load of the pump would increase when operated. 28 By the Chief Officer being assisted by the ASD and the Pumpman. The ship’s engineers were not involved in this

troubleshooting.


1.4.2 The flange

1.4.2.1 The flange was about 10cm in diameter and weighed about 6kg. Six holes on

the flange were used for bolting it onto the pump casing. The diameter of each

hole was about 1.4cm. An inspection of the flange after the occurrence

indicated that the rubber O-ring (gasket) attached to the flange was broken29

(see figure 3).

Figure 3 – Removed flange and newly fixed after the accident

(Source: the ISM Manager and DSB’s investigators30)

1.4.3 The rope

1.4.3.1 The rope in use was of a man-made fibre (likely polypropylene) type about

10mm in diameter. An inspection of the rope confirmed that it was intact and a

knot existed about 30cm from the end. It could not be established how the rope

was secured to the flange by the Pumpman before instructions were given to

the ASD to heave up the rope. (see figure 4).

Figure 4 – The rope in use with a knot (type of knot unidentifiable)


29 It could not be established whether the gasket had broken because of the fall, or during its removal from the pump

casing or was already broken due to wear and tear. 30 Investigators from the Dutch Safety Board (DSB), boarded the vessel to obtain some evidence on behalf of TSIB

when BS called at the port of Rotterdam in Netherlands on 25 August 2018.


1.4.4 The personal protective equipment

1.4.4.1 The Pumpman was wearing personal protective equipment as per the

Company’s SMS while inside the water ballast tank, which comprised the work

coveralls, safety helmet fixed with a torchlight, personal gas detector, and

safety shoes issued by the Company. A set of safety harness was also donned.

The safety helmet31, found on the grating of the bottom platform, was not

cracked but had an inward indentation of about 2cm (see figure 5).

Figure 5 - the indentation of the Pumpman’s helmet, viewed from two angles


1.4.4.2 There was no separate portable lighting prepared for the entry and work to be

carried out on the pump.

1.4.5 Location of Pumpman

1.4.5.1 When the rescue team reached the bottom platform, the Pumpman was noted

to be lying on the right side, on the grating slightly away from the vertical ladder

and the safety helmet was less than a metre away (see re-enactment in figure

6).

31 According to the Company, the helmet used by the Pumpman was a model which met the European standard EN

12492 (the shock absorption test included the ability to protect the head against falling objects at weight of 5kg at a height of 2m).


Figure 6 - Re-enactment of the Pumpman’s position (Source: the ISM Manager)

1.5 The Safety Management System

1.5.1 The Company managed a fleet of oil tankers, chemical tankers and gas

carriers.

1.5.2 A Document of Compliance certificate was issued to the Company by the RO

on 30 January 2014 and it was valid until 1 March 2019 based on the

completion of audit on 9 January 2014. The last audit of the Company’s Safety

Management System (SMS) was carried out on 27 April 2017.

1.5.3 A Safety Management certificate (SMC) was issued to BS by the same RO on

13 January 2018 and was valid until 6 March 2020 based on the completion of

audit on 6 March 2015.

1.5.4 The last Port State Control inspection on BS was carried out on 17 May 2018

at the port of Ulsan. One deficiency32 was issued for the ballast water record

book not meeting the requirement of the BWM Convention regulation B-2

(ballast water record book).

1.5.5 According to the Company’s SMS procedures, a Pumpman would typically

undergo familiarisation training upon joining the ship within a specific period,

such as familiarity with operation of safety equipment33, and deck/cargo

system34 on board. The familiarisation records indicated that the Pumpman had

undergone this familiarisation.

1.5.6 Enclosed space entry35 was categorized as one of the critical operations in the

Company’s SMS procedures. These procedures covered specific areas to

ensure safe operations, such as entry preparation, entry precautions, space

atmosphere checks and emergency procedures. The Chief Officer was

responsible for the overall safety for each entry operation.

32 The deficiency with a Code of 14801, was issued by the Port State Control under the Tokyo Memorandum of

Understanding, the action taken by the inspecting officer was giving an instruction to the ship’s master to correctly fill up the book from then onwards.

33 Safety equipment such as use of gas detector, to be completed within 14 days after joining the ship. 34 Operation of Deck/cargo system such as winches, cargo, ballast pumps, tank cleaning system within one month

after joining the ship. 35 In the Company’s SMS procedures, an enclosed space, other than a cargo tank was considered a space with limited

openings for entry and exit, with unfavorable natural ventilation, not designed for continuous worker occupancy, the atmosphere may be hazardous and those spaces included the ballast tanks.


1.5.7 A responsible person36 typically designated by the Chief Officer, was required

to complete an enclosed space entry checklist (entry permit), before passing it

to the Chief Officer for acknowledgement, and subsequent approval37 of the

ship’s Master before entry into an enclosed space was commenced. The entry

permit was typically valid for eight hours. In addition to the entry permit, a risk

assessment form for the task to be performed (the troubleshooting of the ballast

pump in this case) was also required to be completed by the responsible person

as per the Company’s SMS procedures, which would identify the risks, its

potential consequences, existing and additional control measures for mitigating

the risk.

1.5.8 The leader of the team entering the enclosed space would be required to verify

all items in the entry permit and sign it. The team leader would ensure that

communication was established and tested between the working team

members and the navigating officer38 on the bridge.

1.5.9 According to the Company’s SMS, records of entry permit and related risk

assessments were required to be maintained on board for a period of six

months. Past records indicated that an entry was made for entering other

ballast tanks for inspection by a class surveyor in May 2018. Another enclosed

space entry permit (and related risk assessments) was dated 15 July 2018 (the

latest entry record) for work on the water ballast pump inside 7WBT-P by the

ASD and Pumpman.

1.5.10 On the day of the occurrence, there were no records of an enclosed space

entry permit made or related risk assessment being carried out. According to

the ASD, there was no briefing prior the task being assigned to the ASD by the

Chief Officer. Entry procedures were only verbally discussed between the

Pumpman and the ASD, and that there was no other discussion on the task to

be performed, e.g. lifting of the flange.

36 A certified ship’s officer or petty officer who may be in-charge of a work process involving other crewmembers. 37 The Master was responsible to ensure the safety procedures being followed. 38 As per the Company’s general procedures for entry into enclosed spaces and cargo tanks, the duty (navigating)

officer was required to keep records of persons entering (on entry permit) cargo tanks, after information was given to him/her by the Responsible Person.


1.6 Relevant safe working practice

1.6.1 The COSWP39, was incorporated into the Company’s SMS procedures and

was carried on board its fleet of ships.

1.6.2 Chapter 1.2.4 of COSWP - Managing Occupational Health and Safety -

Planning of work is essential in ensuring occupational health and safety at

work. Adequate control of risks can only be achieved by ensuring that all

involved are aware, activities are co-ordinated and good communication is

maintained by all involved.

1.6.3 While planning the task, consideration of what actions are necessary, how

these will be carried out and what effect they may have on seafarers’ safety at

work, taking into account that there may be consequences that are indirect and

unintended.

1.6.4 Chapter 1.2.5 on risk awareness, highlights that seafarer’s knowledge about

risk can be attained through a combination of conducting risk assessment,

theoretical training, practical application, information sharing, personal

experience, as well as clear instructions and supervision by supervisors.

1.6.5 Chapter 19.21.10, emphasised the importance of communication involving a

lifting operation. An effective means of communication to the authorising officer

and between those involved should be established and maintained to avoid

misunderstandings. This might be by portable hand-held radio or a person-to-

person chain. Action should be taken as a result of the positive receipt of

confirmation that the message is understood.

1.7 Cause of death

1.7.1 There was no autopsy examination report made available to the investigation

team, but the Company revealed that the Pumpman had passed away at the

hospital due to head injuries.

1.8 Environmental condition

1.8.1 According to the ship’s logbook, at the time of occurrence, the weather was

39 Though not a mandatory publication for carriage on Singapore registered ships, the company’s SMS had

incorporated the Code of Safe Working Practices for Merchant Seafarers (COSWP) as the part of procedures for reference. The COSWP, edition 2015, published by the UK Maritime and Coastguard Agency (MCA), provides best practice guidance for improving health and safety on board ships. A copy of COSWP was on board at the time of the accident.


moderate with a westerly breeze (about 11 to 16 knots), the swell height was

about 1.5m, with partly cloudy skies.


2 ANALYSIS

2.1 The occurrence

2.1.1 The Pumpman was working alone inside the ballast tank, and there was no

coordination between the Pumpman and the ASD (who was standing by

outside the tank) on the work to be performed on the pump, except mentioning

that the flange40 could be the cause of loss of suction. As there was no lighting

fitted along the vertical ladder and the bottom of tank, the area could be dim

and it is possible that the ASD could not see how the flange came loose from

the rope and injured the Pumpman.

2.1.2 The flange was considerably heavy and had six holes for it to be bolted on to

the casing of the pump. It could not be established how the rope was tied to the

flange by the Pumpman, but it is likely that the rope was secured to one of the

holes using an inappropriate knot which came off or slipped through when it

was heaved up (discussed separately).

2.1.3 Although the safety helmet used by the Pumpman was certified to protect

against falling objects, the impact force of the 6kg flange from a height of more

than 5m (the ASD recalled heaving the rope for about 6-8m before tension was

lost) had exceeded the certification requirement of the helmet. The high impact

force had caused an inward indentation on the safety helmet which resulted in

the fatal injuries of the Pumpman.

2.1.4 Prior to the occurrence, other than the shout to heave the rope, there was no

other communication between the two crew members. Although the ASD

recalled that the Pumpman was away from the manhole prior to heaving up the

rope, based on the location where the latter’s body was noted after the

occurrence, it was deemed probable that the Pumpman was either approaching

the vertical ladder for climbing up or commenced climbing the vertical ladder to

exit the tank, while the rope was being heaved up by the ASD.

2.1.5 The reason for the Pumpman to stay underneath the flange while it was being

lifted could not be established. One of the possibilities could be that the

Pumpman had wanted to ensure that the flange would not get stuck halfway

when being heaved up. When the flange was halfway up, the Pumpman could

have thought that the flange should be able to be lifted all the way up without

40 Post-accident inspection of the flange indicated that the gasket of the flange was broken. Assuming that the gasket

was found broken when the flange was removed from the pump casing, it had likely prompted the Pumpman to remove the flange from the tank for replacing the gasket at the ship’s engine room workshop.


any issue and had then attempted to get out of the tank using the vertical

ladder. The accident demonstrated the importance of staying clear of an object

that is being lifted.

2.1.6 The ASD had followed the Pumpman’s instruction to heave up an object but

without knowing what was to be heaved and whether the object was being

secured properly. While the ASD had noted that the Pumpman was away from

the manhole before heaving up the flange, there was no coordination to ensure

that the Pumpman would not come under the flange during the heaving

operation. A better coordination between the Pumpman and ASD using the

portable radio would have been desirable when heaving up the flange.

2.2 Type of knot used to secure the flange

2.2.1 Tasks on board a ship invariably involve the use of ropes, for tying, lifting,

securing objects at sea which requiring deckhand skills and are acquired by

ship’s crew over the course of their work experience. Different kind of knots are

used for different type of tasks depending on the object involved and the rope

in use. Since there was no witness as to how the Pumpman tied the rope to the

flange, the investigation team could not establish what kind of knot was used

by the Pumpman.

2.2.2 At sea, it is common for objects to be lifted and to be tied with a Bowline (see

figure 7) knot, which is a relatively simple, commonly used and an effective

knot41.

Figure 7 – A Bowline knot if used to tie the flange, annotated by TSIB

(Source: Open source on seamanship techniques)

2.2.3 In this occurrence the rope in use did not part (refer to figure 4) which means

that the flange had come off from the knot. For a Bowline knot to fail, the end

41 The advantage of the knot is that it will not jam and slip even when it gets wet.


(indicated in the figure 7 with a red tape) would have to come out of the

securing loop twice and end up as a single rope (without any knotted portions).

In this case, the rope was found to have a knotted portion, about 30cm from

the end and thus it is unlikely that a Bowline knot was used to secure the flange.

2.2.4 It is thus likely that the Pumpman had used a different knot (other than a

Bowline) which resulted in the flange slipping out of the rope. As indicated in

this accident, it is important that the correct type of knot is being used for the

intended purpose.

2.3 Risk assessment for shipboard operations

2.3.1 The Company’s SMS required the conduct of risk assessments by a

responsible person for identifying risks, its potential consequences, and

implementing control measures. Similar guidance was provided for in the

COSWP, which recognised the importance of proper planning of work to ensure

all possible risks are addressed and adequate safety control measures are in

place before commencement of a task (see paragraph 1.5.7).

2.3.2 The Pumpman was considered as a Petty Officer according to the Company’s

SMS, and thus deemed as a responsible person capable of conducting risk

assessments on the tasks to be performed. However, there was no evidence

of risk assessments for the work carried out on the ballast pump in the tank.

2.3.3 The Chief Officer had likely deemed the task of solving the ballast pump

problem by the duo as a routine task since they had been working on it in the

past two weeks. As a result, the Chief Officer might have left the risk

assessments to the Pumpman, without adequately ensuring that they were

carried out. Had the risk assessments been discussed in detail with the Chief

Officer, the risks42 associated with objects being lifted out of the tank could

have been identified and addressed accordingly.

2.3.4 This incident highlighted the importance of senior officers in supervisory

position ensuring that risk assessments are carried out for all shipboard

operations.

2.4 Incidental findings

2.4.1 The Company’s SMS classified enclosed space entry as one of the critical

42 The risk of fall could be as a result of either the rope slipping out of the hands of the person heaving it up, or the

rope parting halfway, or the object slipping out while being heaved up, as was in this case.


operations which required compliance with specific procedures before entry

was permitted.

2.4.2 On reviewing past records of enclosed space entry, it was established that the

same set of crew had entered the same ballast tank twice to overhaul the pump

in the past two weeks without completing any enclosed space entry permit or

risk assessment, which was not in accordance with the Company’s enclosed

space entry requirements.

2.4.3 The Pumpman and the ASD, had not enquired from the Chief Officer on the

need for enclosed space entry permits and proceeded to enter the ballast tank

on two occasions. Similarly, the Chief Officer also did not ensure a permit was

obtained before commencement of the tank entry by the crew.

2.4.4 The navigating officer was aware of an entry into 7WBT-P as indicative by the

log book entry at 0855H. However, there was no clarification sought from the

person entering into/standing at 7WBT-P whether an enclosed space entry

permit had been issued. If the task was planned properly, the navigating officer

should have been advised of the intention, who could have also intervened and

ensured compliance with the Company’s enclosed space entry procedures.

2.4.5 While entering the ballast tank without a valid entry permit did not directly

contribute to the accident, it is extremely important for ship’s crew to adhere to

the established procedures in order to cultivate a positive safety culture on

board a ship.

2.4.6 Prioritisation of tasks is also extremely important. In this case, there were two

concurrent tasks being conducted. If indeed remounting of the overhauled air

horn was more critical for the safety of navigation, it would have been desirable

for this task to be prioritised so that additional hands could be arranged for

assistance with the troubleshooting of the ballast pump.

2.4.7 The ballast pump had been giving problems since the installation of the BWTS.

Although the Company’s SMS procedures stated it was the Pumpman’s

responsibility to operate ship’s cargo/ballast pump, troubleshooting the cause

of the loss of suction should have been done with the assistance of engineers

and in consultation with the manufacturer of the ballast pump as well as the

installer of the BWTS if needed, rather than relying on a trial and error method.

It would have been desirable for the matter to be raised to the Company’s

personnel ashore for appropriate follow-up.

2.4.8 When the occurrence took place, BS was transiting piracy prone area. Though


there were navy ships patrolling and a group of security armed guards were

engaged on board, it would be desirable for the Company to (as per the Ship’s

Security Plan43) limit only to essential tasks and operations carried out on board

considering the risk of piracy and the threat to the safety of the ship’s crew

during passage through a high risk area. In this case, it was reasonable for the

air horn to be remounted for the safety of navigation and the troubleshooting of

the ballast pump at 7WBT-P could have been deferred.

43 A confidential document as required under the International Ship and Port Facility (ISPS) Code, meant for the use

of the Ship’s Security Officer and Company’s Security Officer to assess threat levels and implement security measures.


3 CONCLUSIONS

From the information gathered, the following findings, which should not be read

as apportioning blame or determining liability to any particular organisation or

individual, are made.

3.1 The Pumpman was working alone inside the ballast tank and had used a knot

which had not been tied properly and resulted in the flange slipping out of the

rope while it was lifted out of the tank.

3.2 The flange weighing 6kg had come loose and hit on the head of the Pumpman

who was attempting to climb out of the tank. The impact force of the flange had

exceeded the certification requirement of the safety helmet and resulted in

fatally injuring the Pumpman.

3.3 In performing the troubleshooting of the ballast pump, there was a lack of

coordination between the two crew members for ensuring that the Pumpman

was not underneath when the flange was heaved up.

3.4 There was no risk assessment carried out by the two crew members prior to

performing work on the ballast pump as required by the Company’s SMS

procedures. The Chief Officer also did not ensure this was done before

commencement of the work.

3.5 In the course of the investigation, the following incidental findings, though did

not directly contribute to the accident, were important to note for the safety of

shipboard operations:

a. There was no entry permit issued prior to entering the ballast tank (enclosed

space) for performing work on the ballast pump;

b. The troubleshooting of the ballast pump suction problem was left to the

Pumpman instead of involving the engineers on board or makers ashore; and

c. Troubleshooting of the ballast pump at 7WBT-P was being carried out as

per normal when the ship was transiting high risk area.


4 SAFETY ACTIONS

During the course of the investigation and through discussions with the

investigation team, the following safety actions were initiated by the Company.

4.1 Actions taken by the Company

4.1.1 After the occurrence, the Company had carried out its own investigation. Based

on their findings, the following safety actions had been taken to address the

gaps for preventing similar recurrence:

a) A safety poster created and distributed to all its fleet of ships highlighting

the risk involved in using improper knot and other possible risks when

heaving up objects.

b) A set of presentation slides on hazards related to falling objects to be used

for discussion during the General Safety Meetings on board ships.

c) A safety culture campaign was launched in its fleet of ships to address the

safe working attitude and the Stop Work Authority on board.

d) Reviewed its procedures to enhance hazards identification during the work

planning on board ship.


5 SAFETY RECOMMENDATIONS

A safety recommendation is for the purpose of preventive action and shall in no case create a presumption of blame or liability.

5.1 The following safety recommendations are issued to the Company:

5.1.1 To ensure the Company’s SMS procedures are effectively implemented on

board its fleet of ships, particularly to ensure that entry permits are issued for

enclosed space entries and risk assessments are carried out for shipboard

operations; [TSIB-RM-2020-017]

5.1.2 To involve the relevant engineers on board or equipment maker in the

troubleshooting of shipboard equipment defects; [TSIB-RM-2020-018]

5.1.3 To limit tasks to only essential type on deck when its fleet of ships are transiting

in high risk areas. [TSIB-RM-2020-019]

- End of Report -

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